Pain after surgery

Moderately traumatic surgeries can cause significant pain after surgery. Traditional opioids (morphine, promedol, etc.) are not very suitable for patients after such surgeries, since their use, especially in the early period after general anesthesia, is dangerous due to the development of central respiratory depression and requires monitoring the patient in the intensive care unit. Meanwhile, due to their condition, patients after such surgeries do not need to be hospitalized in the intensive care unit, but they do need good and safe pain relief.

Almost everyone experiences some pain after surgery. In the world of medicine, this is considered more the norm than a pathology. After all, any surgery is an intervention in the entire system of the human body, so some time is needed for recovery and healing of wounds for further full functioning. Pain sensations are strictly individual and depend on both the postoperative condition of the person and the general criteria of his health. Pain after surgery can be constant, or it can be periodic, increasing with body tension - walking, laughing, sneezing or coughing or even deep breathing.

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Causes of pain after surgery

Pain after surgery can have different origins. This may indicate the process of wound healing and tissue fusion, because during surgical incision of soft tissues, some small nerve fibers are damaged. This increases the sensitivity of the injured area. Other causes of pain after surgery are tissue swelling. In addition, much depends on how carefully the doctor performs the surgery itself and tissue manipulations, as this can also cause additional injury.

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Symptoms of pain after surgery

A person may not associate the pain that occurs with the previous operation. But there are a number of signs that will help to identify pain after surgery. First of all, you should pay attention to the general condition: pain after surgery is often accompanied by sleep and appetite disturbances, general weakness, lethargy, drowsiness, decreased activity. These pains can also cause decreased concentration, difficulty breathing or coughing. These are the most obvious and easily recognizable symptoms of pain after surgery, if they occur, you should definitely consult a doctor.

Pain after varicocele surgery

Varicocele is a fairly common disease these days. The disease itself is not life-threatening, but it causes a lot of problems for men, both physiological and psychological. Pain after varicocele surgery can be caused by various factors. The most dangerous of them is damage to the genitofemoral nerve, which is located in the inguinal canal, during surgery. The pain is felt in the area of the surgical wound and may be accompanied by decreased sensitivity of the inner thigh. Another reason for pain after varicocele surgery may be an infectious process in the postoperative wound. To avoid this complication, dressings should be done only with a specialist and, as far as possible, avoid contact of the operated area with all kinds of sources of infection. Also, pain after varicocele surgery may indicate hypertrophy or atrophy of the testicle. Thanks to modern medical technologies, in most cases, and this is about 96% of those operated on, no complications arise after surgical manipulations, so pain should be a signal that you must definitely see a doctor, since there is always a chance of being among the 4% of other patients.

Pain after appendicitis surgery

Removal of the appendix is a fairly common and simple operation in our time. Most operations are relatively easy and without complications. Most patients recover within three to four days. Pain after an appendectomy may indicate that complications have arisen. If the pain is cutting, this may be a sign that there has been a slight divergence of the internal sutures, as a result of overexertion. Nagging pain after an appendectomy may indicate that adhesions are occurring, which can subsequently affect the functioning of other pelvic organs. If these pains are too sharp, then there is a possibility that the intestines are being squeezed, which can have an unfavorable outcome without medical intervention. Stress on the intestines can also cause pain after an appendectomy, so it is worth carefully monitoring your diet in the first period after surgery. In addition, it is worth handling the postoperative suture as carefully as possible to avoid infection and suppuration in the postoperative area.

Abdominal pain after surgery

After abdominal surgery (as after any other surgical intervention), the body's tissues need time to recover and heal. This process is accompanied by mild painful sensations, which decrease over time. But if the abdominal pain after surgery becomes very intense, this may indicate some inflammation at the site of surgery. Also, abdominal pain after surgery can cause the formation of adhesions. People with increased sensitivity to weather conditions may feel aching pain at the site of surgery depending on changes in weather conditions. Abdominal pain after surgery may be accompanied by nausea, dizziness, burning in the postoperative area, redness. If such symptoms occur, you should consult a specialist.

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Pain after inguinal hernia surgery

After an inguinal hernia operation, there is a slight pain syndrome for some time after the operation, which disappears as the sutures and tissues heal. After a short period of time after the operation, the patient can already move independently, but still feel pain in the abdominal area when walking. Pain after an inguinal hernia operation may not always indicate problems with the scar. This can be pain of both a neurological and muscular nature. But with heavy loads in the postoperative period, relapses may occur, which are accompanied by sharp pain and require repeated surgical intervention. Painful sensations at the suture site can be a sign of both external and internal suture divergence.

Pain after spine surgery

Some time after spinal surgery, characteristic pain may occur in the area of the operated area. Most often, pain after spinal surgery indicates a poor-quality operation, which subsequently leads to the development of a postoperative scar - fibrosis. This complication is characterized by specific pain that appears after several weeks of good health. Pain after spinal surgery in most cases has neurological causes. It can also be a relapse of the disease caused by improper adherence to the postoperative regimen. Most patients feel pain after spinal surgery, but as they recover, its intensity should decrease. Recovery usually takes from three to six months. In case of too intense pain, there are a number of methods for solving this problem, from drug treatment to consultation with neurosurgeons and repeated surgery. Spinal surgeries are among the most complex and dangerous operations and often entail complications, so no pain after spinal surgery can be ignored.

Back pain after surgery

Back pain often persists after surgery. This can be caused by a whole range of reasons, such as scar formation, neurological symptoms, various pinched or displaced areas of the spine. To avoid complications after surgery, you need to carefully follow your doctor's recommendations regarding the rehabilitation program. Back pain may also occur after a cesarean section. This is a fairly common problem that should not be ignored, because during pregnancy and surgery, a woman's spine is heavily loaded, which can lead to various injuries. Often, after surgery, pain appears in the lower back, in the lumbar region. This is due to the formation of adhesions and the negative impact of cicatricial changes. Pain between the shoulder blades often appears after breast surgery, with tension in the rhomboid muscle. Spinal anesthesia is often used during surgery, which can subsequently cause aching back pain.

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Headache after surgery

Headache after surgery is associated with the specifics of surgical manipulations or signals an increase in intraocular pressure due to surgery. Also, headache after surgery can be a consequence of anesthesia, especially if the pain is accompanied by nausea and dizziness. This is a fairly dangerous symptom, which in any case requires an urgent consultation with a neurologist or the doctor who performed the surgery. After spinal anesthesia, complaints of headaches are more common than after regular general anesthesia. Such a complication occurs if too large a hole was made in the spinal cord membrane, resulting in a significant increase in intracranial pressure. If in this case the pain is very severe, then the hole is sealed with blood. Also, headache after surgery can be a side effect of drugs that are prescribed for the postoperative period.

Pain after hemorrhoid surgery

If the pain after hemorrhoid surgery persists for a long period, which exceeds the rehabilitation period predicted by the doctor, then the postoperative treatment is insufficient or ineffective in a particular case and requires immediate correction. Severe pain after hemorrhoid surgery may be a consequence of scarring. In cases where the scars are too dense, intestinal ruptures may occur, which will recur each time during defecation. Also, pain after hemorrhoid surgery may indicate the ingress of pathogenic microflora into the postoperative wound and, accordingly, suppuration. One of the unpleasant causes of pain may be a fistula, which requires serious treatment. Pain after hemorrhoid surgery should decrease as the wound heals and tissues are restored.

Pain after abdominal surgery

During each operation, the entire human organ system takes on a huge load. This process is accompanied by a significant stress state, which is aggravated by the presence of pain after abdominal surgery. The body's reaction to open surgery can last up to three days and be expressed in severe pain, increased temperature or pressure, tachycardia. Because of this, patients quite often have a depressed mood and decreased activity during the rehabilitation period, which significantly slows down the recovery process. Pain after abdominal surgery is relieved by opiate drugs, sedatives and anti-inflammatory drugs. During the intake of drugs, pain after abdominal surgery subsides, body temperature returns to normal, motor activity increases. Over time, the body is almost completely restored, there may be complaints only about minor pain in the abdomen, which also completely disappears over time. After three to four weeks, if the rehabilitation routine and diet are followed, the body's activity stabilizes, swelling subsides, pain disappears and a scar is formed.

Pain after lung surgery

If severe chest pain occurs after lung surgery, this is an alarming signal that you need to see a doctor. Such pain may be a symptom of pulmonary hemorrhage, which appeared as a complication after surgery. Also, pain after lung surgery may indicate the formation of adhesions. Adhesions themselves are not a disease and do not always require medical intervention, but if the adhesion process is accompanied by a cough, fever and poor general health, then this may require treatment. Pain after lung surgery can occur with sudden motor activity, which may be a sign of inflammation or suppuration in the operated area. Lung surgery is a very serious operation, which often results in complications. In the first period after surgery, the body is supplied with oxygen much worse, which can cause headaches, difficulty breathing and tachycardia. Resistance to diseases such as bronchitis or pneumonia also increases. It is also worth remembering that after surgery, the lungs increase in volume, filling the free space, which can lead to the displacement of other organs in the chest. All this can be the cause of pain after lung surgery.

Muscle pain after surgery

Most often, muscle pain after surgery occurs in young men. The pain syndrome is usually associated with the use of curare-like drugs during anesthesia, which relax the muscles. Such drugs are used in emergency situations or in cases where food was consumed shortly before the operation and the stomach remains full during the operation. Muscle pain after surgery is a consequence of anesthesia. Usually, these pains are "wandering", they are symmetrical and affect the shoulder girdle, neck or upper abdomen. With a favorable course of the rehabilitation period, muscle pain after surgery disappears after a few days. Also, nagging muscle pain appears after laparoscopy and continues for some time until complete recovery. In addition, aching pain in the muscles near the postoperative scar may remain for a long time after surgery, as a reaction to weather changes.

How to relieve pain after surgery?

Most people experience some degree of pain after surgery. Such pain can vary in nature and duration and increase with certain body positions or movements. If the pain becomes too severe, narcotic analgesics are usually used. These drugs are most effective when the patient needs to get out of bed or the pain is unbearable and weaker painkillers do not help. In some cases, the dosage of these drugs can be increased or supplemented with other drugs. It should be noted that such drugs can cause addiction and negative reactions of the body, so they should be taken as needed and under the supervision of a doctor or medical staff. In no case should you take strong painkillers that have a narcotic effect on your own. This can lead to side effects such as nausea, excessive sedation, and disruption of the favorable course of rehabilitation. You should contact your doctor, who will prescribe how to relieve pain after surgery, taking into account the individual characteristics of the surgical manipulations and the body. For moderate pain, doctors recommend using non-narcotic analgesics. This is paracetamol, which, when dosed correctly, causes virtually no side effects on the body and has high tolerance. There are many folk methods to relieve pain after surgery, but traditional doctors still strongly advise against self-medication, since in the postoperative period the body is most susceptible to all sorts of irritants and may react inadequately to self-medication.

To protect against pain after surgery with an emphasis on preventive (before injury and pain) protection, it is recommended to use the principle of multimodality and an integrated approach. When drawing up a postoperative analgesia plan, a number of general principles should be followed:

• therapy should be etiopathogenetic (if the pain is of a spastic nature after surgery, it is sufficient to prescribe an antispasmodic rather than an analgesic);
• the prescribed medication must be adequate to the intensity of pain after surgery and be safe for the person, not causing significant side effects (respiratory depression, decreased blood pressure, rhythm disorders);
• the duration of use of narcotic drugs and their doses should be determined individually depending on the type, causes and nature of the pain syndrome;
• monotherapy with narcotics should not be used; narcotic analgesics for pain relief after surgery should be combined with non-narcotic drugs and adjuvant symptomatic drugs of various types in order to increase their effectiveness;
• Anesthesia should be prescribed only when the nature and cause of pain sensations have been identified and a diagnosis has been made. Removing the symptom of pain after surgery with an unspecified cause is unacceptable. When following these general principles, each doctor should, as Professor N.E. Burov points out, know the pharmacodynamics of the main range of painkillers and the pharmacodynamics of the main adjuvant agents (antispasmodics, anticholinergics, antiemetics, corticosteroids, antidepressants for anxiety-suspicious states, anticonvulsants, neuroleptics, tranquilizers, antihistamines, sedatives), assess the intensity of pain after surgery and, depending on this, apply a unified tactic.

To ensure the unity of tactics, it is proposed to use a scale for assessing the intensity of pain after surgery. The role of such a scale is played by the "analgesic ladder" developed by the World Federation of Societies of Anesthesiologists (WFOA). The use of this scale allows achieving satisfactory pain relief in 90% of cases. The scale provides for gradation of pain severity after surgery.

At the 3rd stage - minimally expressed pain after surgery - monotherapy with non-narcotic drugs is carried out to relieve pain.

At the 2nd stage, a combination of non-narcotic analgesics and weak opioids is used, mainly with their oral administration. The most specific and reliable option for pain relief after surgery is the effect on the central link, therefore, drugs of central action are mainly used to relieve pain after surgery. Examples of such analgesics can be butorphanol and nalbuphine.

Butorphanol tartrate is a kappa- and weak antagonist of mu-opiate receptors. As a result of interaction with kappa receptors, butorphanol has strong analgesic properties and sedation, and as a result of antagonism with mu receptors, butorphanol tartrate weakens the main side effects of morphine-like drugs and has a more beneficial effect on respiration and blood circulation. For more severe pain, buprenorphine is prescribed. The analgesic effect of butorphanol tartrate with intravenous administration occurs after 15-20 minutes.

Nalbuphine is a new generation of synthetic opioid analgesics. In pure form, in a dose of 40-60 mg, it is used for postoperative pain relief in extracavitary surgeries. In major intracavitary surgeries, monoanalgesia with nalbuphine becomes insufficient. In such cases, it should be combined with non-narcotic analgesics. Nalbuphine should not be used in combination with narcotic analgesics due to their mutual antagonism.

The direction of creating combined drugs with different mechanisms and time characteristics of action also seems promising. This allows achieving a stronger analgesic effect compared to each of the drugs at lower doses, as well as reducing the frequency and severity of adverse events.

In this regard, combinations of drugs in one tablet are very promising, allowing to simplify the regimen of administration significantly. The disadvantage of such drugs is the impossibility of varying the dose of each component separately.

At the 1st stage - with severe pain - strong analgesics are used in combination with regional blockades and non-narcotic analgesics (NSAIDs, paracetamol), mainly parenterally. For example, strong opioids can be administered subcutaneously or intramuscularly. If such therapy does not have a sufficient effect, drugs are administered intravenously. The disadvantage of this route of administration is the risk of severe respiratory depression and the development of arterial hypotension. Side effects such as drowsiness, adynamia, nausea, vomiting, impaired peristalsis of the digestive tract, and motility of the urinary tract are also noted.

Medicines for pain relief after surgery

Most often in the postoperative period, pain relief is required after surgery at the level of the 2nd stage. Let us consider in more detail the medications used in this case.

Paracetamol is a non-selective COX-1 and COX-2 inhibitor acting primarily in the CNS. It inhibits prostaglandin synthetase in the hypothalamus, prevents the production of spinal prostaglandin E2 and inhibits the synthesis of nitric oxide in macrophages.

In therapeutic doses, the inhibitory effect in peripheral tissues is insignificant, it has minimal anti-inflammatory and antirheumatic effects.

The action begins quickly (after 0.5 hours) and reaches its maximum after 30-36 minutes, but remains relatively short (about 2 hours). This limits the possibilities of its use in the postoperative period.

In the treatment of postoperative pain, a 2001 systematic review of high-quality evidence including 41 high-quality studies showed that the efficacy of 1000 mg after orthopaedic and abdominal surgery was similar to other NSAIDs. In addition, the rectal form was shown to be effective at a single dose of 40-60 mg/kg (1 study) or multiple doses of 14-20 mg/kg (3 studies), but not at a single dose of 10-20 mg/kg (5 studies).

The advantage is the low frequency of side effects when using it; it is considered one of the safest analgesics and antipyretics.

Tramadol remains the fourth most commonly prescribed analgesic worldwide, used in 70 countries, with 4% of prescriptions for post-operative pain.

Tramadol is a synthetic opioid analgesic, a mixture of two enantiomers. One of its enantiomers interacts with opioid mu, delta, and kappa receptors (with greater affinity for mu receptors). The main metabolite (Ml) also has an analgesic effect, with its affinity for opiate receptors being almost 200 times greater than that of the original substance. The affinity of tramadol and its Ml metabolite for mu receptors is significantly weaker than the affinity of morphine and other true opiates, so although it exhibits an opioid effect, it is classified as a medium-strength analgesic. The other enantiomer inhibits neuronal uptake of norepinephrine and serotonin, activating the central descending inhibitory noradrenergic system and disrupting the transmission of pain impulses to the gelatinous substance of the brain. It is the synergy of its two mechanisms of action that determines its high effectiveness.

It should be noted that it has a low affinity for opiate receptors, due to which it rarely causes mental and physical dependence. The results obtained over 3 years of drug research after its introduction to the market in the USA indicate that the degree of drug dependence development was low. The overwhelming majority of cases of drug dependence development (97%) were identified among individuals who had a history of drug dependence on other substances.

The drug does not have a significant effect on hemodynamic parameters, respiratory function and intestinal peristalsis. In postoperative patients under the influence of tramadol in the range of therapeutic doses from 0.5 to 2 mg per 1 kg of body weight, even with intravenous bolus administration, no significant respiratory depression was found, whereas morphine in a therapeutic dose of 0.14 mg/kg statistically significantly and significantly reduced the respiratory rate and increased the CO2 tension in exhaled air.

Tramadol also does not have a depressant effect on blood circulation. On the contrary, when administered intravenously at 0.75-1.5 mg/kg, it can increase systolic and diastolic blood pressure by 10-15 mm Hg and slightly increase heart rate with a rapid return to baseline values, which is explained by the sympathomimetic component of its action. No effect of the drug on the level of histamine in the blood or on mental functions has been noted.

Postoperative analgesia based on tramadol has proven itself positively in elderly and senile patients due to the absence of a negative impact on the functions of the aging organism. It has been shown that with epidural blockade, use in the postoperative period after major abdominal interventions and after cesarean section provides adequate pain relief after surgery.

The maximum activity of tramadol develops after 2-3 hours, the half-life and duration of analgesia is about 6 hours. Therefore, its use in combination with other, faster-acting painkillers seems more favorable.

Combination of drugs for pain relief after surgery

Combinations of paracetamol with opioids are recommended for use by the WHO and are the best-selling combination analgesics for postoperative pain relief abroad. In the UK in 1995, prescriptions for paracetamol with codeine (paracetamol 300 mg and codeine 30 mg) accounted for 20% of all analgesic prescriptions.

The following drugs from this group are recommended: Solpadeine (paracetamol 500 mg, codeine 8 mg, caffeine 30 mg); Sedalgin-Neo (acetylsalicylic acid 200 mg, phenacetin 200 mg, caffeine 50 mg, codeine 10 mg, phenobarbital 25 mg); Pentalgina (metamizole 300 mg, naproxen 100 mg, caffeine 50 mg, codeine 8 mg, phenobarbital 10 mg); Nurofen-Plus (ibuprofen 200 mg, codeine 10 mg).

However, the potency of these drugs is not sufficient for their widespread use in postoperative pain relief.

Zaldiar is a combination drug of paracetamol and tramadol. Zaldiar was registered in Russia in 2004 and is recommended for use in dental and postoperative pain, back pain, osteoarthritic pain and fibromyalgia, pain relief after minor and moderately traumatic surgeries (arthroscopy, herniotomy, sectoral resection of the mammary gland, thyroid resection, saphenectomy).

One tablet of Zaldiar contains 37.5 mg of tramadol hydrochloride and 325 mg of paracetamol. The dose ratio (1:8.67) was chosen based on the analysis of pharmacological properties and has been proven in a number of in vitro studies. In addition, the analgesic efficacy of this combination was studied in a pharmacokinetic/pharmacodynamic model in 1,652 subjects. It was shown that the analgesic effect of Zaldiar occurs in less than 20 minutes and lasts up to 6 hours; thus, the effect of Zaldiar develops twice as fast as that of tramadol, lasts 66% longer than that of tramadol, and 15% longer than that of paracetamol. At the same time, the pharmacokinetic parameters of Zaldiar do not differ from the pharmacokinetic parameters of its active ingredients and no undesirable drug interactions occur between them.

The clinical efficacy of the combination of tramadol and paracetamol was high and exceeded the efficacy of tramadol monotherapy at a dose of 75 mg.

To compare the analgesic effect of two multicomponent analgesics - tramadol 37.5 mg / paracetamol 325 mg and codeine 30 mg / paracetamol 300 mg, a double-blind, placebo-controlled study was conducted in 153 people for 6 days after arthroscopy of the knee and shoulder joints. On average, by group, the daily dose of tramadol / paracetamol was comparable to that of codeine / paracetamol, which amounted to 4.3 and 4.6 tablets per day, respectively. The effectiveness of the combination of tramadol and paracetamol was higher than in the placebo group. According to the final assessment of the pain relief result, the pain intensity during the day was higher in the group of patients who were pain relieved with a combination of codeine and paracetamol. In the group receiving a combination of tramadol and paracetamol, a more pronounced decrease in the intensity of the pain syndrome was achieved. In addition, adverse events (nausea, constipation) occurred less frequently with tramadol and paracetamol than with codeine and paracetamol. Therefore, combining tramadol 37.5 mg and paracetamol 325 mg allows for a reduction in the average daily dose of the former, which in this study was 161 mg.

A number of clinical trials of Zaldiar have been conducted in dental surgery. A double-blind, randomized, comparative study conducted in 200 adult patients after molar extraction showed that the combination of tramadol (75 mg) with paracetamol was not inferior in effectiveness to the combination of paracetamol with hydrocodone (10 mg), but caused fewer side effects. A double-blind, randomized, placebo-controlled, multicenter study was also conducted, including 1,200 patients who underwent molar extraction, comparing the analgesic efficacy and tolerability of tramadol 75 mg, paracetamol 650 mg, ibuprofen 400 mg, and the combination of tramadol 75 mg with paracetamol 650 mg after a single dose of the drug. The total analgesic effect of the tramadol and paracetamol combination was 12.1 points and was higher than that of placebo, tramadol and paracetamol used as monotherapy. In patients of these groups, the total analgesic effect was 3.3, 6.7 and 8.6 points, respectively. The onset of action in analgesia with the tramadol and paracetamol combination was observed on average in the group at the 17th minute (with a 95% confidence interval of 15 to 20 minutes), while after taking tramadol and ibuprofen, the development of analgesia was noted at the 51st (with a 95% confidence interval of 40 to 70 minutes) and 34th minutes, respectively.

Thus, the use of a combination based on tramadol and paracetamol was accompanied by an increase and prolongation of the analgesic effect, a more rapid development of the effect compared to that observed after taking tramadol and ibuprofen. The duration of the analgesic effect was also higher for the combined drug tramadol and paracetamol (5 hours) compared to these substances separately (2 and 3 hours, respectively).

The Cochrane Collaboration conducted a meta-analysis (review) of 7 randomized, double-blind, placebo-controlled studies in which 1,763 patients with moderate or severe postoperative pain received tramadol in combination with paracetamol or monotherapy with paracetamol or ibuprofen. The indicator of the number of patients who need pain therapy to reduce pain intensity by at least 50% in one patient was determined. It was found that in patients with moderate or severe pain after dental operations, this indicator during 6 hours of observation for the combined drug tramadol with paracetamol was 2.6 points, for tramadol (75 mg) - 9.9 points, for paracetamol (650 mg) - 3.6 points.

Thus, the meta-analysis showed a higher efficacy of Zaldiar compared to the use of individual components (tramadol and paracetamol).

In a simple, open, non-randomized study conducted at the Russian Scientific Center of Surgery, Russian Academy of Medical Sciences, in 27 patients (19 women and 8 men, average age 47 ± 13 years, body weight 81 ± 13 kg), with moderate or severe pain in the postoperative period, Zaldiar administration was started after complete recovery of consciousness and gastrointestinal function. The study included patients with acute pain after surgery due to abdominal (laparoscopic cholecystectomy, herniotomy), thoracic (lobectomy, pleural puncture), and extracavitary (microdiscectomy, saphenectomy) surgical interventions.

Contraindications to the administration of the drug were: inability to take it orally, hypersensitivity to tramadol and paracetamol, use of centrally acting drugs (hypnotics, hypnotics, psychotropic drugs, etc.), renal (creatinine clearance less than 10 ml/min) and hepatic insufficiency, chronic obstructive pulmonary diseases with signs of respiratory failure, epilepsy, use of anticonvulsants, use of MAO inhibitors, pregnancy, breastfeeding.

Zaldiar was prescribed in standard doses: 2 tablets for pain, with the maximum daily dose not exceeding 8 tablets. The duration of pain relief therapy ranged from 1 to 4 days. In case of insufficient pain relief or lack of effect, other analgesics were additionally prescribed (promedol 20 mg, diclofenac 75 mg).

Pain intensity was determined using a verbal scale (VS). The initial pain intensity was recorded, as well as its dynamics during 6 hours after the first dose of Zaldiar; assessment of the analgesic effect using a 4-point scale: 0 points - no effect, 1 - insignificant (unsatisfactory), 2 - satisfactory, 3 - good, 4 - complete pain relief; duration of the analgesic effect; duration of the course; the need for additional analgesics; registration of adverse events.

Additional analgesics were required in 7 (26%) patients. Throughout the observation period, pain intensity along the VS ranged from 1 ± 0.9 to 0.7 ± 0.7 cm, which corresponds to pain of low intensity. Only in two patients, Zaldiar was ineffective, which was the reason for discontinuing the drug. The remaining patients rated pain relief as good or satisfactory.

Moderate pain intensity after surgery according to the VS was observed in 17 (63%) patients, severe pain - in 10 (37%) patients. On average, pain intensity according to the VS in the group was 2.4 ± 0.5 points. After the first dose of Zaldiar, adequate pain relief was achieved in 25 (93%) patients, including satisfactory and good/complete pain relief in 4 (15%) and 21 (78%) patients, respectively. A decrease in pain intensity after the initial dose of Zaldiar from 2.4 ± 0.5 to 1.4 ± 0.7 points was noted by the 30th minute (the first assessment of pain intensity) of the study, and the maximum effect was observed after 2-4 hours, 24 (89%) patients indicated a clear decrease in pain intensity by at least half, and the duration of the analgesic effect was on average 5 ± 2 hours in the group. The average daily dose in the Zaldiar group was 4.4 ± 1.6 tablets.

Thus, the appointment of Zaldiar in case of severe pain after surgery or moderate intensity is advisable from the 2nd-3rd day of the postoperative period, 2 tablets. In this case, the maximum daily dose should not exceed 8 tablets.

The tolerability profile of Zaldiar, according to various studies, is relatively favorable. Side effects develop in 25-56% of cases. Thus, in the study [20], nausea (17.3%), dizziness (11.7%) and vomiting (9.1%) were noted during the treatment of osteoarthritis. At the same time, 12.7% of patients had to stop taking the drug due to side effects. No serious side effects were registered.

In a study of postoperative patients, the tolerability of the drug and the frequency of adverse reactions during analgesia with the combination of tramadol 75 mg/paracetamol 650 mg were comparable to those in patients taking tramadol 75 mg as the only analgesic. The most common adverse events in these groups were nausea (23%), vomiting (21%), and drowsiness (5% of cases). Discontinuation of Zaldiar due to adverse events was required in 2 (7%) patients. None of the patients experienced clinically significant respiratory depression or allergic reaction.

In a four-week multicentre comparative study of tramadol/paracetamol (Zaldiar) and codeine/paracetamol combinations in patients with chronic post-surgery back pain and osteoarthritis pain, Zaldiar demonstrated a more favourable tolerability profile (less frequent side effects such as constipation and drowsiness) compared with the codeine/paracetamol combination.

In a meta-analysis by the Cochrane Collaboration, the incidence of adverse events with the use of a combination drug of tramadol (75 mg) with paracetamol (650 mg) was higher than for paracetamol (650 mg) and ibuprofen (400 mg): the index of potential harm (an indicator of the number of patients during whose treatment one case of an adverse event developed) was 5.4 (with a 95% confidence interval from 4.0 to 8.2). At the same time, monotherapy with paracetamol and ibuprofen did not increase the risk compared to placebo: the relative risk indicator for them was 0.9 (with a 95% confidence interval from 0.7 to 1.3) and 0.7 (with a 95% confidence interval from 0.5 to 1.01), respectively.

When assessing adverse reactions, it was found that the combination of tramadol/paracetamol does not lead to increased toxicity of the opioid analgesic.

Thus, when relieving pain after surgery, the most appropriate seems to be the planned use of one of the NSAIDs in the recommended daily dose in combination with tramadol, which allows achieving good analgesia in an active state of operated patients without serious side effects characteristic of morphine and promedol (drowsiness, lethargy, hypoventilation of the lungs). The method of postoperative pain relief based on tramadol in combination with one of the peripheral analgesics is effective, safe, and allows pain relief for the patient in a general ward, without special intensive monitoring.

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